On May 5th, after rescinding prior publications, the DME MACs issued a revised joint publication to address coverage and coding guidelines for ventilators. At first glance there were no material changes, but the language is notably softer on several key statements regarding coverage. This is one of many signs that CMS is listening to the industry and clinical organizations that are seeking more intuitive ventilator coverage interpretations.

Since issuing a 2001 decision memo, CMS has educated that ventilators are decidedly distinct from Respiratory Assist Devices (RAD). The memo’s backdrop compared RAD for Chronic Obstructive Pulmonary Disease (COPD) to invasive ventilation administered through an intubated airway. It further established that ventilators should be utilized when “failure of respiratory support leads to death”. These seven words severely limit the application of ventilator coverage and have guided MAC ventilator coverage decisions since the issuance of the memo.

In the revised publication we do not see any reference to the decision memo. Instead, it acknowledges the overlap between diagnoses found in the RAD Local Coverage Determination (LCD) and those in the ventilator National Coverage Determination (NCD). And the revised guidance softens the education, “the determination to use a ventilator vs. a bi-level PAP device, is made based upon the specifics of each individual beneficiary's medical condition”. The medical record must make it clear why the unique volume feature (which can only be provided by a ventilator) is required to treat a beneficiary’s condition and symptoms. Based on the revised guidance, it appears that the MACs are steering away from the old decision memo.

Without directly saying so, CMS continues to quietly reassess the coverage guidance for ventilators. Adapting these educational materials to acknowledge the overlap of disease groupings between RAD and ventilators, while acknowledging that treatment plans for these patients will vary based on specifics in each case, are significant milestones.

We will be talking through this update and other behind the scenes issues impacting ventilator suppliers on June 8th with HME News. Reserve your seat for this event here.